For the first months of the pandemic, the mayor of La Grande, Oregon, governed a city whose residents regarded COVID-19 as somebody else’s problem; something for big cities to worry about.
Then, suddenly, it was La Grande’s problem.
"They got used to the belief that the virus wasn't going to get us here. Even though I wore a mask, I was very relaxed about this whole thing," Mayor Stephen Clements told OPB in June, shortly after over a hundred COVID-19 cases in his county were linked to a church service. La Grande is in the rural Northeast corner of Oregon, hours from the nearest major metropolitan center.
Sometimes Oregonians talk about the eastern and western halves of the state like two different entities: one urban, one rural; one white collar and one blue collar, one dominated by liberal cities and one populated almost entirely by conservatives. In the first few months of the COVID-19 pandemic, it seemed like an urban disease. Rural Oregonians
that limited movement, kept them in their homes and shuttered businesses.
But as the coronavirus pandemic rages on, it’s revealing that however divided Oregon may seem, the state is very interconnected. Rural areas face their own unique challenges fighting this virus — and some that mirror those in big cities.
Multnomah County, with the most cases in Oregon, is also the state's most populous county. But the five counties with the highest per-capita number of cases are all rural, and the four hardest-hit counties are located in the dry, eastern side of the state. For every hundred people in Umatilla, Malheur, Union, and Morrow counties, almost 1.5 people have the new coronavirus — about five times higher than the rate in Multnomah County. And that's just confirmed cases.
The first two counties to experience large outbreaks were Union County, where La Grande is, and, across in the state, Newport in coastal Lincoln County. Both outbreaks were identified not long after Memorial Day weekend.
“When you look at these two outbreaks on either side of the state, both were centers where people got together, where people traveled,” said Charlie Tveit, the chair of the Oregon Association of Hospitals and Health System’s Small and Rural Hospital Committee.
Hot spots and roadside attractions
Newport is a tourist hot spot, and was inundated with visitors over Memorial Day Weekend. “And in La Grande, you have a lot of people travelling along Interstate 84,” Tveit said.
I-84 stretches from Portland to Boise and beyond to Salt Lake City making small towns along the freeway like La Grande frequent stopping-off places for people from all over.
“There’s this belief that Eastern Oregon is just people living isolated at the end of a long dirt road,” said Tveit, who is also CEO of the Lake County Health District, which serves one of Oregon’s most remote and least populous regions. “It’s a shame that people have that view, because it’s not true.”
Few people live on thousand-acre ranches. Most inhabit the wide-open spaces of Eastern Oregon from within the comfy confines of small towns. And even those more remote people come into town: to get food, get gas, to get to work.
Moey Newbold is the director of urban planning at Central Oregon Landwatch. Bend, Oregon, is the largest city east of the Cascade crest. As it’s grown, many commuters and workers have been pushed to surrounding Central Oregon communities dozens of miles away.
"People can't afford housing in Bend, so they've been pushed to rural areas like Prineville, LaPine, and Redmond," Newbold said.
But those people still come into town to commute dozens of miles and shop at Bend’s high-volume supermarkets and other retailers, which are the only nearby options for residents of communities east of the city. Rural and small-town dwellers may not risk bumping into a coronavirus-exposed individual in, say, the halls of an apartment building, but there are still gathering places where transmission risks run high.
The outbreak in La Grande was originally linked to a church service. In Newport, it was linked to a food processing plant. In Morrow County, transmission is also tied to the food industry. Summer brings agricultural work, and it's difficult for those gathering and processing food to practice social distancing.
In urban areas like Multnomah County, which has remained under fairly strict lockdown measures, many people have white-collar jobs that let them work from home, and less are employed in crowded factory conditions. Most COVID-19 case clusters have been small, linked to gatherings and person-to-person transmission. The outbreaks in rural Oregon probably started that way, too: but they went unnoticed. COVID-19 can spread before people develop symptoms, and some people might have such mild cases they’re unaware they have the disease. It isn’t until a person, or several people, get sick that the larger outbreaks are identified.
Since the COVID-19 outbreak, Xinhua Yu, an epidemiologist at the University of Memphis, has been studying differences in access to healthcare for elderly individuals in urban and rural areas.
Why rural places are vulnerable
“From an epidemiological point of view, there are going to be some cases travelling from urban areas to rural areas,” Yu said. “But in COVID-19, you may only need one case to infect a large portion of that rural area.”
Because there are fewer grocery stores, gas stations, churches, employers and central gathering places per capita, it’s much easier for the virus to infect a large percentage of the population, Yu said. In other words, the odds are good that a person will visit the same location where someone infected with the virus has been.
It helps to think of COVID-19 like a wildfire, sending off sparks. Most of those sparks don’t do anything — they jump and burn out without spreading the fire. It’s likely plenty of COVID-19 sparks have flown into rural Oregon communities in the last few months, and fizzled out unnoticed. Sometimes the fires happen quickly, as soon as the spark touches down.
But over time, any one of those sparks can land at a nursing home, or a food processing plant, or the only grocery store for 50 miles. Then suddenly the blaze is too large to miss. Just like how lightning-struck trees smolder for weeks unnoticed until the conditions are right for a dry breeze to set them alight.
“Are rural communities more at risk?” Tveit asked, “I think they’re equally at risk. So the big question is, do we have enough resources?”
In Oregon, rural areas have fewer contact tracers, less available personal protective equipment for medical workers, like surgical masks and face shields, and less access to testing.
“Even if we tested everyone, my goodness, one of the requirements for our hospital to open up long-term care is that all staff and residents get tested every week!”
But his hospital doesn’t have enough of the government-provided rapid test kits to regularly test employees. They need to save those tests for people who are actually sick, to determine how to treat them.
The Oregon Health Authority issued guidelines that state the number of contact tracers a county must employ to re-open during the pandemic. In some cases, only a handful were required. Yu says that's not enough. "The thing about contact tracing is it's exponential, you have to call and test all of an infected person's contacts. And then those people's contacts. And so on. It's not going to work if you only have one to three people doing that."
The Oregon Health Authority has additional contact tracers they can deploy in the event of an outbreak, but when several outbreaks happen simultaneously, the system falls down, too. Return times for commercial COVID-19 test kits, which are often relied on in large outbreaks, have been increasing. That means it might take weeks for people to find out if they're sick — weeks during which they can be spreading the disease, making contact tracing even harder.
More vulnerable to strain
Remote, small-town hospitals are also more vulnerable to strain than are hospitals in cities and suburbs. Most rural hospitals, like the Lake County Health District, are critical-access hospitals. That means they have fewer than 25 beds, minimal staff, and are not set up for long-term care of critically ill patients. During flu season, it’s not uncommon for the hospitals to fly patients to larger medical centers in urban areas.
Demographics put rural populations at greater risk, too.
“In rural areas across the country, a large percentage of residents are elderly people,” Yu said. That might seem counterintuitive, “because elderly people have more needs in terms of healthcare and services.”
But it’s a lot harder for an older person to relocate than it is for a younger person. So while younger adults may choose to move to urban areas, older residents remain. And those residents might have a larger number of underlying health conditions, explained Yu.
Workers at factories and processing plants are also at risk. They make less money than urban workers, and have less access to healthcare, sick leave, and unemployment benefits. It’s harder for them to take time off work if they might be sick: they need the money to live.
While these inequalities are particularly visible in rural communities, they aren’t unique to them. Urban centers struggle with contact tracing, social networks, and testing, too.
Across the state, only about a quarter of all COVID-19 cases can be linked to a previously-identified case. The virus is spreading in every county: but right now, there's not enough testing or contact tracing to contain it. And until those resources come, said Yu, "all we can do is educate ourselves."